2004 OPEN FORUM Abstracts
ENDOTRACHEAL TUBE CHANGES IN NEWBORNS AND INFANTS; DON’T BELIEVE EVERYTHING YOU SEE.
Posen M.D., Bernard Halabi RRT,RCP, John Cefaratt B.S.,RRT,NPS Neonatal
ICU - Huntington Memorial Hospital Pasadena, California
Background: Endotracheal tube placement in newborns and infants is usually confirmed by chest x-ray. Normally the ET-tube tip should be between T-2 and T-3. Often times tube placement is misinterpreted and ordered to be repositioned a measured distance to correct a perceived error.This is done with potential risks to the patients mucosa and face along with inadvertent extubation.
Method: A retrospective chart review identified ten patients, randomly selected, with a total of 408 ventilator days. Within that time period ET-tubes were moved in and out 113 times. A tracking form was developed which required the RT to be present at the bedside and to fill in a column of the form with each x-ray, thus verifying correct neutral position of the head and body as well as tube placement by lip level. After implementing the tracking form a second random chart review was initiated.
Results: To date five patients have been reviewed with 27 ventilator days thus far. Of those 27 days the ET-tubes had been repositioned four times. Before the form was instituted there was a27.2% change rate/day. After the form there has been a 14.8% change rate. This is a 12.9% drop in position changes per ventilator.
Experience: It has been noted that even though RTs are present in the NICU they may not always be present at the bedside for the x-ray. Having the form as a monitor to insure the best placement of the patient for x-ray will minimize erroneous reports of tube placement. Many patients have had their ETtube moved in and out multiple times in the course of their ventilatory care. Often times unnecessarily if the head and body had been properly placed or taken into consideration when the film was read.
Conclusion: With the implementation of a tracking form RTs are more aware of patient body position, ETtube securing point and head and chin position for x-rays. If a tube appears out of the acceptable range by chest x-ray, the tracking form will reveal a plausible explanation that would negate reposition-ing the tube, in addition a closer inspection of the chest x-ray itself should help identify position errors i.e. body rotation, neck flexed or extended, foreign objects under the patient. Minimizing tube repositioning decreases risks of mucosal damage and facial skin breakdown.